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couldn't get the hang of his three-physician group's electronic health record (EHR) system. That struggle had led to one- to two-hour waits for patients.

Learn more about encouraging EHR use among physicians

The physician, who did not return a request to be interviewed by SearchHealthIT.com, wrote in an April 12 letter to patients that the transition to EHR use had been "most difficult."

"Not being able to type and feeling very awkward in the use of computer documentation, ordering and billing have limited my ability to effectively and in a timely manner see my patients, return calls and send out lab reports," the physician wrote.

He went on to apologize for long patient waits and said he did not foresee his ability to achieve enough "familiarity and comfort" with EHR use to resolve the problem. Instead of continuing his practice, he concluded, he will "turn to rehabilitative and administrative aspects of medicine."

Economics worsening primary care physician shortage

That's a tough decision to take because of the nation's grave shortage of primary care docs, said Dr. David Kibbe, senior advisor to the American Academy of Family Physicians (AAFP), co-developer of the Continuity of Care Record (CCR) health data standard and solo physician advocate. He believes the problem will get worse for the next decade before things improve. He sees new payment models such as the accountable care organization (ACO) sending more patients to more primary care physicians more often.

Kibbe points out that implementing EHR systems and accomplishing meaningful use criteria -- in concert with rising operating costs and new reimbursement models such as ACOs -- is putting difficult financial pressure on family physicians. While some analysts might give health IT observers the impression that older physicians are retiring rather than going paperless, Kibbe is not seeing those early retirements. Instead, independent physicians are joining large groups.

"That amount of stress and challenge and change, really, is what's behind many of these smaller practices closing up shop," Kibbe said. "But it's going to be hard for some of these docs to quit and walk away. Some of these docs in their early 60s who would love to retire may not be able to afford it."

Competency in EHR use part of Mass. physician licensure

When told of the primary care physician who ceased practicing, Massachusetts Medical Society President Dr. Alice Coombs said it "greatly" concerned her. "That one doctor may be taking care of two or three thousand patients. Those patients have to scramble for a new doctor. Taking a doctor out of a community like that leaves the community at a deficit."

Like all Massachusetts doctors, the physician also was required to comply with the state's Section 305 law. It mandates that physicians demonstrate competency in EHR use by 2015 to maintain licensure.

Section 305 caused a stir among physicians, Coombs said. Her group lobbied the Massachusetts Board of Registration in Medicine licensing authority to come up with a simple method for confirmation of health IT competency. The board eventually determined that physicians could demonstrate EHR competency by taking a continuing medical education (CME) course, which it had done for other recent state mandates for demonstrating competencies in risk management and opiate prescription.

"By 2015 most doctors will be using EHRs in their practices and won't think much about it."

Dr. David Kibbe, senior advisor, American Academy of Family Physicians

Coombs said her society endorses the use of EHR systems, noting that members believe the technology will eventually improve patient care and promote patient participation in their care. To that end, she said doctors were not offended by the decision to use CME courses to demonstrate IT competency. "We have to do CMEs anyway to get licensure."

RECs form safety net, provide training for EHR use

Solo physicians -- or those working for small groups -- who are contemplating closing their doors have a federally funded safety net in their regional extension center (REC). These organizations provide support in the transition from paper records to EHR systems.

Bethany Gilboard is director of health technologies for the Massachusetts Technology Collaborative that administers the Massachusetts eHealth Institute REC. She said her organization not only helps physicians choose EHR systems that make sense for their practices -- the REC also hires experts to analyze and optimize a practice's workflow, give on-site training to employees using the software and generally "do a lot of hand-holding" to make sure the implementation gets done well.

When doctors have trouble with EHR use, they can always approach the vendor for help to learn the system and fix workflow issues. But that comes at considerable cost, Gilboard said. While the Massachusetts REC recently met its goal of signing up 2,500 physicians, thousands more in the state could benefit from services it offers for free or at reduced rates by enrolling, she added.

Physicians who either can't type or flat-out refuse to learn to type, Gilboard conceded, will have a difficult time transitioning from paper workflows to EHR systems.

"A lot of physicians who can't type may have people in their office who can type," she said. "There's no question that you need to have a certain degree of knowing your way around a keyboard and a mouse. Or, you take a course. Take one online, at night, at home. No one has to know you don't know how to type."

Speech recognition, training can help EHR implementation

Mavis Beacon typing courses were exactly the prescription that a few of the 300 physicians at the Fallon Clinic needed to cure their EHR implementation ills, said medical director of informatics Dr. Larry Garber, who oversaw the rollout in 2009. Some physicians who couldn't type also opted to learn speech recognition software, which did take some effort to master.

Still others, Garber said, had problems reading small print onscreen; Fallon provided big-screen monitors for them. Beyond that, one-on-one assistance with customizing the EHR system -- such as setting software preferences and documentation tools -- helped get physicians up to speed in their clinical workflows.

The situation of the physician who quit practicing over EHRs was probably "quite preventable," Garber said. The keys to helping physicians who are having a hard time getting the hang of an electronic workflow at Fallon included listening to the physicians describe their specific problems and then tailoring a solution to their particular issues.

"Every physician is different; some do have specific needs," Garber said. "Most of the complaints that we got turned out to be things that we could make better. In other words, they weren't people whining -- they were intelligent people recognizing things that should be done a better way, more efficiently."

iPad, simpler EHR implementation coming

None of the experts interviewed for this article had heard of a physician giving up completely because of a failed transition to an EHR system. Some have sought help through RECs. Some have joined large groups and let the corporation handle the EHR implementation.

Kibbe has advised a few older physicians to just hold on to paper until they wrap up their careers. In the same breath, he added, he tells these older physicians to at least try to get their feet wet with paperless processes by making a small component of their practices electronic, such as setting up an e-prescribing system.

By the time meaningful use rules are fully in effect in 2015, Kibbe expects EHR systems to be simpler and less expensive, resembling familiar Internet applications such as Flickr, Facebook and Expedia. EHR vendors are driving this trend by hiring physicians to design their software in more intuitive ways; in turn, that will help complete health care's transition from paper.

"We're now starting to get residents coming out of programs in family medicine, internal medicine, pediatrics, and so forth who have never used a paper chart -- in other words, a whole generation of physicians who are ready to use these systems," Kibbe said. "When you combine those things with the federal government's complete redesign of what electronic health records should do, it makes me think that by 2015 most doctors will be using EHRs in their practices and won't think much about it."

Touchscreen tablets such as the Apple Inc. iPad and its Android brethren may ease the transition for physicians having trouble with EHR use, both Kibbe and Gilboard said. Internet connectivity makes it easier to look up drug data and other traditionally time-consuming tasks on those devices. Both also said smartphones have great potential to improve patient care.

But even if these don't, Kibbe said efforts should be made to prevent family physicians from quitting, even though they might have missed the information age.

"I don't think people like that should be run out of medicine," Kibbe said. "I think he should find a place where he can do his thing and not have to [quit]."